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retina, or a touch of the finger-tip. When Argyrol, anywhere from twenty-five to we imagine each of the 2,000,000 private fifty per cent solution, should be dropped paths connected to each of the 500,000 into the eye every two hours after cleanscommon paths, or perhaps each connected ing. At least once a day the eyelids to each through many and diverse routes, should be everted and the argyrol rubbed we arrive at some notion of the complex into the palpebral conjunctiva very thority of the vital keyboard.
oughly by means of cotton twisted about These lectures are to be published in the end of a cotton holder. Where dropbook form by Yale University.
ping the argyrol in in the ordinary way 400 Prospect Avenue.
has failed in arresting the secretions, I
have found it to be arrested in two or [Written for the MEDICAL BRIEF. ]
three days after applying it in this wayOphthalmia Neonatorum.
rubbing it in. The argyrol is superior to BY DAVID WEBSTER, M, D.,
all other applications because, while thorProfessor Emeritus of Ophthalmology in the New oughly efficient as a bactericide, it pro
York Polyclinic; Surgeon Manhattan Eye duces no pain, smarting, burning or irriand Ear Hospital; Consulting Ophthalmic
tation whatever. Surgeon to the Hospital for Ruptured and Crippled; Consulting Physician to the Skin
The chief danger in these cases is from and Cancer Hospital; Fellow of the Academy ulceration of the cornea. An ulcer may of Medicine, American Medical Association, be arrested at almost any stage, or, in Etc., Etc., Etc. New York City.
spite of all treatment, it may go on to the Ophthalmia neonatorum is one of the destruction of the whole cornea. Ulcers, forms of conjunctivitis which, without however, rarely appear in this disease if proper treatment, is moderately certain to the case is treated early, and in the way destroy the eyesight. It makes its ap I have indicated. pearance within a few days of the birth of Quite a large proportion of our cases at the infant, and is undoubtedly in nearly the Manhattan Eye and Ear Hospital all instances due to gonorrheal infection. come to us after a week or more of neg.
At the Manhattan Eye and Ear Hos lect, and after the eye has either been depital, where a considerable number of stroyed or sloughing of the cornea or ul. these little patients are constantly under ceration has already set in. In these treatment, routine examinations of the cases, of course, the most we can expect is conjunctival secretion are made, and gon to save partial vision. ococci are almost always found in large Very rarely, indeed, only one eye is af. numbers, and the patients are never dis fected. In such a case the other eye must charged until gonococci are no longer be most carefully protected from the first, found in the secretions.
either by a bandage or by Buller's shield, The symptoms of this disease are red if it can be kept on the eye of the little one. ness of the eyeball, swelling of the eyelids, As the disease is almost certain to be often chemosis, and a very abundant caught, if any of the secretion gets purulent discharge.
into the eyes of the nurse, or any Treated conscientiously and energetic other person, the greatest care should be ally, such a case will be nearly well in taken to destroy all things that have been about two weeks.
applied to the eye. The ice cloths and the The treatment consists in constant cotton with which the eyes were wiped cleansing with a warm saturated solution should be put into a newspaper cornucoof boric acid; as often as any secretion pia and conveyed to the furnace. The appears it should be washed away care nurse should be exceedingly careful to fully, and this usually requires a repeti wash her hands thoroughly after having tion of the washing every fifteen or used them about the eyes of the child so twenty minutes. Ice cloths should be ap as not to commmunicate the disease to plied as much as possible, but it is very herself or anyone else. I have known difficult to keep them on the eyelids of more than one nurse to lose her sight these little patients, who are usually nerv through carelessness in taking care of Cuis, and are constantly moving their children with ophthalmia neonatorum. heads about, and removing the ice cloths. | 327 Madison Avenue.
ties is to decide whether the case is one which can be treated at the patient's own home with a reasonable prospect of recovery for himself, and safety to those around him, or whether immediate removal to an asylum is necessary. Should the case occur in a large town, the advice of a skilled alienist can readily be obtained, but in remote country districts the whole burden of responsibility is thrown on the shoulders of the practi. tioner, and it is often a heavy one.
In the present short paper it is only possible to deal with those forms of in. sanity which are most likely to be met with in everyday practice, and to call urgently for treatment, and these my own experience has shown to be: mania, melancholia, delusional insanity or paranoia, general paralysis, puerperal insanity, and alcoholic insanity. Three-fourths of all cases admitted to asylums are examples of either mania or melancholia, and, indeed, almost every case of insanity can be assigned to either the maniacal or the melancholic type, and these have been spoken of as the pure or primary psychoses.
As in the course of this paper I shall have occasionally to refer to hallucinations, illusions and delusions, it is well here to differentiate between them, as they are often confused with one another.
Hallucinations are false perceptions of the senses-sight, hearing, taste, smell, or common sensation. They occur in many forms of insanity, but, on the other hand, a person may have hallucinations, and yet not necessarily be insane; he may recognize them as such.
Illusions are mistaken perceptions of the senses. The patient does actually see, hear, etc., something, but he mistakes it for something entirely different; he may, for example, see clouds in the sky and mistake them for armies fighting in the air.
If a patient believe in his hallucinations or illusions he is insane.
A delusion is a false belief in some fact which may have reference to the senses, as when a man thinks a rat is gnawing at his vitals, or it may be quite independent of these, as when he fancies he is a monarch, or the Messiah, or a great general, and so forth.
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[Written for the MEDICAL BRIEF.) On the Management of Insanity in Private Practice, With Some
Hints as to Prognosis.
BY EDWARD GEORGE YOUNGER, M, D., M. R. C.
P., D. P. H., Senior Physician to the Finsbury' Dispensary and Late Physician to the St. Pancras and Northern Dispensary.
London, England. A case of insanity occurring in the practice of the general physician is almost certain to be the cause of much anxiety and worry to him unless he has had special training in the subject of mental diseases, which is rarely the case. The problems as to diagnosis, prognosis and treatment call urgently for prompt solution, and one of the greatest difficul
A person who has delusions is necessar The utmost the family physician can do ily insane.
is to endeavor, pending removal, to proAlmost all cases of insanity are pre cure abatement of the noisy and conceded by a stage which is known as the stant excitement, and here chloral hydrasperiod of emotional alteration. This may tis is a useful drug, but in administering either be well-marked or very slight. The it we must always bear in mind that the patient may have neglected his business, tendency to death in acute mania is by and his habits and temper may have al asthenia. It is important, also, to rememtered; alternate periods of depression and ber that opium and its alkaloids are excitement may have taken place; head worse than useless in acute mania. Even ache and insomnia are generally marked if a strong hypodermic dose of morphine symptoms, and a general rule is that the induce sleep for an hour or two, the pa. greater the insomnia the more rapid is tient invariably wakes unrefreshed, and the progress towards undoubted insanity. in a more excited state than he was before If the physician be fortunately called in
its administration. during this period of emotional excite Sub-Acute or Hypomania differs from ment, an attack of insanity may often be acute merely in degree, as its name imwarded off by judicious treatment of the
plies. In its very mildest form, little may insomnia by such drugs as trional, sul
be observable beyond some excitement, phonal, and chloralamid. Warm baths,
usually of an hilarious character, with also, with cold affusion to the head, will restlessness and diminished power of apoften procure refreshing sleep.
plication. The more pronounced forms It will be advisable, I think, for me to
approach more nearly to the type of acute give a short description of the symptoms
mania, though stopping short of the noisy of each of the forms of insanity I am
excitement and dirty habits. about to deal with:
The mild form is often transient, and MANIA.
may get well without any treatment at all. Acute, Sub-Acute or Hypomania, Chronic | It is, however, likely to recur, and should Mania.-Acute mania has a brief promon it do so it will be probably in a more acitory stage, generally unrecognized, but centuated form. In this mild variety, usually taking the form of restlessness treatment without removal to an asylum and slight depression, after which there may be tried with a reasonable expectais a burst of violent excitement, with tion of success. Rest, change of air and noisy incoherence, which may continue occupation, with the bromides, especially for days and nights together, the sense of the ferrous bromide, in five-grain dosesinuscular fatigue being altogether want will be useful. It is desirable to avoid ing. The tongue is furred, skin sweating both narcotics and alcoholic stimulants, and offensive, the bowels constipated, as in these cases a craving is easily estaburine scanty and high-colored. The hair lished. is harsh, and has lost its natural gloss. In the more pronounced form of hypoThe habits are probably wet and dirty. mania, asylum treatment is the best. ReThe restless excitement may continue for covery in a few weeks, or possibly months, days and nights together, the sense of will most probably take place, though a muscular fatigue being altogether want very few cases drift into chronicity.
Chronic Mania is rarely seen in private The prognosis in early single attacks is practice, its victims usually being already good, but as the attacks multiply, it be inmates of asylums. The symptoms vary comes less favorable, and the disease greatly. The delusions may be many or may end in chronic mania or dementia. few. Some of these patients are docile There is in all cases a somewhat remote and work fairly well under supervision, danger of the patient dying of maniacal but they are nearly all liable to outbreaks exhaustion.
of maniacal excitement at irregular interAs regards treatment, this can only be vals, home treatment being, therefore, out carried out in an asylum, or a lunatic hos of the question. More or less brain depital, and the sooner the patient is re generation is always present, and the moved the better for him and his friends. prognosis is most unfavorable.
scene, and two trained attendants, for, on Simple Melancholia, Melancholia with account of the tendency to suicide, he Delusions, Agitated Melancholia, Stupor must never be left alone, especially in ous Melancholia, or Melancholia Attonita,
the morning hours, for the reason menChronic Melancholia.—Some of the above tioned above. The principal objects of will need merely a passing notice, as in
treatment, after constant supervision, are them home treatment is quite impossible.
to obtain sleep, to give adequate and even Simple Melancholia.-This in its mild abundant nourishment, and to relieve the est form amounts merely to depression of usual constipation. spirits, with gloomy and desponding In all cases of melancholia, solid food, thoughts, forebodings of evil, and a gen- | if the patient will take it, is much more eral pessimistic view of life, but without beneficial than the most nutritious slop any irrationality. It has been said that diet. Obstinate refusal of food will often those who have suffered from a bad attack disappear after a few days' complete rest of "the blues" have had an experience of in bed. Should forcible feeding become a mild form of simple melancholia. In necessary, or should the promptings to the more severe form all the symptoms suicide be very marked, asylum treatment become accentuated, the patient becomes is indicated. In the insomnia of melanhopeless and despairing; he sleeps badly, cholia, in great contradistinction to that and awakens from his broken rest in deep of mania, some of the preparations of despondency.
opium and morphia are valuable; they do It is in this stage that promptings to not seem to aggravate the constipation, suicide are likely to manifest themselves, and the drug habit does not seem to get and here it is important to remember that formed in these cases. The Turkish bath a melancholiac's symptoms are, as a rule, is a useful adjunct. Some very good remost pronounced in the morning, and are sults have lately been obtained from the likely to ameliorate as the day wears on, high-frequency current. The constipation so that if a melancholy patient destroys must be treated on general lines, but no himself, the deed is almost always done medicine should ever be administered surin the morning hours. In early simple reptitiously, i. e., mixed with the food or melancholia, the great question arises as drink. to where ordinary depression of spirits Melancholia with Delusions.-In these ends, and true melancholia begins. It is cases, hallucinations of hearing are very important also to ascertain, if possible, common, and next in order come those of whether any suicidal impulse is present, sight, smell and taste. Those of smell are but leading questions on this subject must of grave import, and generally point to be carefully avoided.
incurable insanity, very likely of alcoThe prognosis in simple melancholia is holic origin. These patients often think generally good, though improvement is their souls are lost, and that they have slower than in corresponding cases of committed the unpardonable sin. They mania. Most recoveries take place very commonly recover, but their progress within twelve months, and improvement is slow, and may extend, with relapses, in the general health, with increasing ap even over a few years. Occasionally the petite, is usually of good augury. Some disease becomes chronic. Asylum treatcases, however, become chronic.
ment is imperative. It is these cases of simple melancholia Agitated Melancholia is commonest in which are most likely to do well outside women. The patient is never still for one an asylum. The very mild ones, like moment, but paces the room, or sits rockthose of mild hypomania, will often re ing her body to and fro, sobbing and cover without any treatment beyond a moaning. She may tear her hair, or pick rest from work, a change of air, and an her skin into sores. Hallucinations are occasional mild hypnotic (chloralamid not, as a rule, present, but the delusions for chronic). In the more marked cases, are numerous and distressing. She may if home treatment be decided upon, the think she has brought ruin on all her patient should be in sufficiently good cir friends; that her soul is lost, and so cumstances to afford a change of air and I forth. It is a curious fact that these patients, in spite of their despair, are not, been under consideration. However, I as a rule, actively suicidal, and they often find the dangerous proclivities vary much take their food well. A large number get with the patient's natural temperament, well eventually, but improvement is slow. whether irascible and hasty, or gentle and Here, again, asylum treatment is the only patient. The person of the former temcourse to pursue.
perament will assuredly seek to revenge Stuporous Melancholia or Melancholia himself on his persecutors, and, perhaps, Attonita.—These patients will sit for commit a murderous assault on some inhours in one position, plunged in melan offensive person, while one of the latter choly, and seeming to take no notice of may content himself with tearful and pitetheir surroundings, but they will almost ous protests to his friends. certainly attempt suicide if they get a I have now under my observation two chance. They sleep badly, and are unwill cases of paranoia of the latter type, both ing to take food. A great many of them men, and both are at present at large and gravitate towards a condition of dementia. following their employment after a They can only be managed in an asylum. fashion. One of them has hallucinations
Chronic Melancholia.—This, like chronic of smell, delusions that people are spreadmania, is rarely met with in general prac ing reports that he has had syphilis, and tice. It is usually a result of one of the an erroneous idea that his rectum is obacuter forms. These cases are unsuited structed. The other thinks he is pointed for home treatment, for although remis at in the streets, watched in all his movesions are common, relapses are equally so, ments, and that there is a conspiracy and, during the latter, suicidal impulses against him. They are both timid, paare often very marked. The tendency is tient men, and, in my opinion, most unalways towards incurable weak-minded likely at present to act on their delusions, ness.
but rather to take them "lying down.” Delusional Insanity or Paranoia.—This They will, no doubt, come to an asylum is a chronic disease characterized by fixed sooner or later, as every paranoic must, delusions, and unaccompanied by any but as each is able to earn a small living, failure of the reasoning faculties. These and as neither of them shows at present fixed delusions are generally of a dis any signs of violence, I think I am justiagreeable nature. The patient often fied in taking the risk. thinks that strangers can read his General Paralysis.—This terrible and thoughts, and they make gestures to him fatal malady usually makes its appearon the streets. Another common delusion ance between the ages of thirty-five and is that paragraphs in the papers refer to fifty. It is much commoner in men than him. Hallucinations of hearing, taste and in women. Many of its early symptoms smell are common. Soon he becomes in. are physical rather than psychical, such dignant and resentful, and he is then as hesitation and slurring of speech, fibrilprone to assault some passerby as the lary tremors of lips, tongue and facial author of the annoyances. Later on, de muscles, pupillary changes, enfeebled gait, lusions of grandeur commonly develop, and slight attacks of "faintness." These and all his irascibility tends to be swal may be accompanied or followed by a silly lowed up by his conceit as weak-minded kind of elation of spirits, forgetfulness, ness becomes more marked. The progno drowsiness, neglect of business, and, later, sis is bad, but these patients often live to by the well-known myalomania, with dea great age.
lusions of wealth and grandeur, when the It has been said that all paranoics are patient will squander money on useless potential homicides, and that for this rea articles. He may, sooner or later, find son an asylum is the only place for them. his way to a police court in consequence There is much truth in this, but there is of some absurd act of indecent exposure, another side to the question. The power | or some senseless theft. of self-control in some of these patients is Soon the attacks of "faintness" develop very great, and I have latterly taken this into epileptiform seizures known as convery much into calculation when the ques gestive attacks. Remissions of all the tion of placing them in an asylum has | symptoms very often take place, and may